Hindawi Publishing Corporation

Emergency Medicine International

Volume 2011, Article ID 161375, 5 pages
doi:10.1155/2011/161375

Review Article
The Emergency Management and Treatment of Severe Burns

Melanie Stander and Lee Alan Wallis

Division of Emergency Medicine, Stellenbosch University, Cape Town 7505, South Africa

Correspondence should be addressed to Melanie Stander, melaniestander@sun.ac.za

Received 18 February 2011; Accepted 10 May 2011

Academic Editor: Aristomenis K. Exadaktylos

Copyright © 2011 M. Stander and L. A. Wallis. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Burn injuries continue to cause morbidity and mortality internationally. Despite international collaborations and preventative
measures, there are still many cases reported in high- and low-income countries. The treatment of these patients is often protracted
and requires extensive resources. The adequate resuscitation of these patients coupled with meticulous wound care can have a huge
impact on their outcome. The authors present a simple guideline for the initial management of severe burns which is utilised by
the South African Burn Society and is based on the guidelines of the American Burn Association and the Australian and New
Zealand Burn Association.

1. Introduction
Burn wounds and injuries are often devastating. They can
have severe long-term consequences for the victims and
they continue to be a major problem affecting communities
worldwide [1]. The treatment of these patients is often
protracted, and large amounts of resources are often needed
to achieve the medical and psychological healing that needs
to occur. Prevention is the vital factor that will have an
impact on decreasing the morbidity and mortality associated
with burns [2–4]. Education and training are vital steps
to empower communities to help them protect themselves,
and also the most vulnerable of burn victims are children.
There have been studies into the different epidemiological
factors related to burn injuries [5–11] with the subsequent
introduction of training programmes, community outreach
and social development, and the development of safe and
effective household practices. These include initiatives like
the Global Alliance for Clean Cookstoves [12]. International
organisations like the World Health Organisation’s Depart-
ment of Violence and Injury Prevention and Disability (VIP)
and the International Society for Burns Injuries (ISBI) strive
to ultimately decrease this significant scourge by improving
data collection, research collaborations, and preventative
strategy development [13].
Statistics from the WHO demonstrate that there are over
300,000 deaths per year from fires alone with many more
from scalds, electrical burns, and other sources but there
is still no accurate global data to confirm these numbers
[13]. Over 95% of fatal fire-related burns occur in low-
and middle-income countries [13]. Multitudes more patients
have survived their injuries but are often left disfigured
and destitute. Children and the elderly remain the most
vulnerable groups with the highest mortality [13]. Intensive
and specialised burn centres are in existence all over the
world but are very often situated in high-income countries.
These innovative and expensive treatment modalities play
an important part, but the way in which a burn patient is
initially managed carries an equally important role. Simple
adherence to the basics including adequate resuscitation and
meticulous wound care go a long way to achieving favourable
outcomes and even in influencing mortality rates [14]. The
following guidelines are based on the South African Burn
Society management guidelines [15] which in turn are based
on the American Burn Association [16] and Australian and
New Zealand Burn Association guidelines [17].
2. Minimal Criteria for Transfer to
a Burn Centre
Burn injury patients who should be referred to a burn unit
include the following:
(i) all burn patients less than 1 year of age;
2 Emergency Medicine International
(ii) all burn patients from 1 to 2 years of age with burns
>5% total body surface area (TBSA);
(iii) patients in any age group with third-degree burns of
any size;
(iv) patients older than 2 years with partial-thickness
burns greater than 10% TBSA;
(v) patients with burns of special areas—face, hands,
feet, genitalia, perineum or major joints;
(vi) patients with electrical burns, including lightning
burns;
(vii) chemical burn patients;
(viii) patients with inhalation injury resulting from fire or
scald burns;
(ix) patients with circumferential burns of the limbs or
chest;
(x) burn injury patients with preexisting medical dis-
orders that could complicate management, prolong
recovery, or affect mortality;
(xi) any patient with burns and concomitant trauma;
(xii) paediatric burn cases where child abuse is suspected;
(xiii) burn patients with treatment requirements exceeding
the capabilities of the referring centre;
(xiv) septic burn wound cases.
3. Treatment Protocol
3.1. Remove any Sources of Heat
(1) Remove any clothing that may be burned, covered
with chemicals, or that is constricting.
(2) Cool any burns less than 3 hours old with cold tap
water (18 degrees centigrade is adequate) for at least
30 minutes and then dry the patient.
(3) Cover the patient with a clean dry sheet or blanket to
prevent hypothermia.
(4) Use of Burnshield [18] is a very effective means of
cooling and dressing the injury for the first 24 hours.
(5) Rings and constricting garments must be removed.
3.2. Assess Airway/Breathing
(1) Careful airway assessment must be done where there
are flame or scald burns of the face and neck.
Intubation is generally only necessary in the case of
unconscious patients, hypoxic patients with severe
smoke inhalation, or patients with flame or flash
burns involving the face and neck. Indications for
airway assessment include the presence of pharyngeal
burns, air hunger, stridor, carbonaceous sputum, and
hoarseness.
(2) All patients with major burns must receive high-flow
oxygen for 24 hours.
(3) Always consider carbon monoxide poisoning in burn
patients. They may have the following symptoms:
restlessness, headache, nausea, poor co-ordination,
memory impairment, disorientation, or coma. Ad-
minister 100% oxygen via a non-rebreathing face
mask; if possible, measure blood gases including
carboxyhaemoglobin level.
(4) If breathing seems to be compromised because of
tight circumferential trunk burns, consult with the
burn centre surgeons immediately regarding the need
for escharotomy.
Circulation
(1) Stop any external bleeding.
(2) Identify potential sources of internal bleeding.
(3) Establish large-bore intravenous (IV) lines and pro-
vide resuscitation bolus fluid as required in all com-
promised patients, using standard ATLS protocols
[19]. Perfusion of potentially viable burn wounds is
critical.
Estimate the Percentage Total Body Surface Area (%TBSA)
Burned (See Figure 1). Initially, use the Rule of Nines. In the
case of all paediatric patients and for a more accurate assess-
ment, use the Berkow diagram; alternatively, the patient’s
unstretched open hand represents 1% of TBSA.
Reminder. Accurate estimation of burn size is critical to
ongoing fluid replacement and management.
3.3. Ongoing Losses (Once the Patient Has Been Stabilised)
(1) Patients with <10% TBSA burns can be resuscitated
orally (unless the patient has an electrical injury or
associated trauma). This needs ongoing evaluation
and the patient may still require an IV line.
(2) In the case of patients with burns 10–40% TBSA, se-
cure a large-bore IV line; add a second line if trans-
portation will take longer than 45 minutes.
(3) Burns >40% TBSA require 2 large-bore IV lines.
(4) If the transfer will take less than 30 minutes from the
time of call, do not delay transfer for an IV line.
Reminder. IV lines may be placed through the burned area
if necessary (suture to secure). Avoid the saphenous vein if
at all possible, and avoid cut-downs through unburned skin
if possible. An intraosseous line is an excellent alternative in
children.
(5) Initiate fluids for ongoing resuscitation and fluid
losses using the Parkland formula
 
4 mL crystalloid × kg of body weight
(1)
× (%burn) = mL in first 24 hours,
Emergency Medicine International 3

Patient name and date of birth Date completed Type of burn

Date and time of burn

9% 9% Superficial
Superficial (pink, painful, moist)
1% 1%

Front
9%
18%
9% 9% 9% % Total %
Back burn
18% + =
18% 18% 18% 18%
Indeterminate %
or deep
Indeterminate or deep
%
White, mottled, dark red
or black, leathery

Paediatric adjustments 18%

(i) Weight approximated to (8 + age × 2)

Front
(ii) <1 year—head and neck are 18% and each leg 14% of BSA 9% 18% 9%
Back
(iii) >1 year—for each year of life 18%
(a) Head decreases by 1% of BSA
(b) Leg increases by 0.5% of BSA 14% 14%

Fluids

(i) Total % burn × weight × 3.5 mL = total fluid in 24 hours .

(ii) Total fluid in 24 hours /2 = volume in first 8 hours since burn
Volume in next 16 hours since burn
(iii) In children, add maintenance fluid to the above calculated volume
.
Note:
. If urine output is not adequate, increase fluids
. for the next hour to 150% of calculated volume
until urine output is adequate.

Figure 1: South African Burn Society Burn Assessment Form.

with half of this total given in the first 8 hours after
injury (note that this is the time from burn, not from
presentation to healthcare services). Children must
have their daily maintenance fluids added to these
replacement fluids (including dextrose).
Example 3.1. In the case of a patient weighing 70 kg with
a 50% TBSA burn, (4 × 70 × 50) = 14 000 mL needed in
the first 24 hours. Half is needed in the first 8 hours after
injury.
Example 3.2. The fluid requirements of a child weighing
15 kg with a TBSA burn of 40% (4 × 15 × 40) = 2400 mL in
the first 24 hours plus maintenance requirements of 1250 mL
(1000 mL + 250 mL) = 3650 mL in the first 24 hours. Half is
needed in the first 8 hours after injury.
Reminder. Do not give dextrose solutions (except for main-
tenance fluids in children)—they may cause an osmotic
diuresis and confuse adequacy of resuscitation assessment.
Ideally, use Ringer’s lactate or normal saline for replacement
fluid and a 5% dextrose-balanced salt solution for the child’s
maintenance.
This is only a guide, and ongoing evaluation is essential as
patients may need more fluids than calculated. Use the patient’s
vital signs and, most importantly, urine output to guide ongoing
requirements.
3.4. Assess Urine Output (This Is the Best Guide to Resuscita-
tion)
(1) Insert a Foley catheter in patients with burns >15%
TBSA. Adequate urine output is 0.5 mL/kg/h in
adults and 1.5 mL/kg/h in children.
Reminder. Lasix and other diuretics must not be given to im-
prove urine output; increase IV fluid rates to increase urine
output.
4 Emergency Medicine International
(2) Observe urine for burgundy colour (seen with mas-
sive injuries or electrical burns). There is a high inci-
dence of renal failure associated with these injuries,
requiring prompt and aggressive intervention.
Reminder. If the urine is red or brown consult a burn centre.
3.5. Insert a Nasogastric Tube. Insert a nasogastric tube in
any patient with burns >30% TBSA, or any patient who is
unresponsive, shocked, or with burns >20% if preparing for
air or long-distance transportation.
3.6. Decompression Incisions (Escharotomy). Assess for cir-
cumferential full-thickness burns of the extremities or trunk.
Elevate the burned extremities on pillows above the level of
the heart. If transfer will be delayed, discuss indications and
methods for decompression incisions (escharotomies) with a
burn surgeon.
3.7. Medication
(1) Give tetanus immunisation.
(2) After fluid resuscitation has been started, pain medi-
cation may be titrated in small intravenous doses (not
intramuscular). Blood pressure, pulse, respiratory
rate, and state of consciousness should be assessed
after each increment of IV morphine.
3.8. Wound Care
(1) Debridement and application of topical antimicro-
bials are usually unnecessary. Initial wound care
needs to ensure that the burn is kept covered and
the patient is kept warm. Plastic food wrap (such as
Gladwrap) is ideal.
(2) Apply a thin layer of silver sulfadiazine to open areas
if transportation will be delayed for more than 12
hours.
(3) Use of Burnshield is a very effective means of cooling
and dressing the injury in the first 24 hours.
3.9. General Items
(1) A history, including details of the accident and preex-
isting diseases/allergies, should be recorded and sent
with the patient.
(2) Copies of all medical records, including all fluids
(calculation of fluids administered) and medications
given, urine outputs, and vital signs must accompany
the patient. These specific details may be recorded on
the back of the burn size assessment sheet.
(3) The burn centre will arrange transport if appropriate.
(4) In the case of paediatric patients not accompanied
by a parent, obtain consent in consultation with your
burn centre.
3.10. Special Considerations with Chemical Burns (Consult
Burn Centre)
(1) Remove all clothing.
(2) Brush powdered chemicals off the wound, then flush
chemical burns for a minimum of 30 minutes using
copious volumes of running water. Be careful to
protect yourself.
Reminder. Never neutralise an acid with a base or vice versa;
the heat generated can worsen the burn.
(3) Irrigate burned eyes using a gentle stream of saline.
Follow with an ophthalmology consultation if trans-
portation is not imminent.
(4) Determine what chemical (and what concentration)
caused the injury.
3.11. Special Considerations with Electrical Injuries (Consult
Burn Centre)
(1) Differentiate between low-voltage (<1000 v) and
high-voltage (>1000 v) injuries.
(2) Attach a cardiac monitor; treat life-threatening dys-
rhythmias as needed.
(3) Assess for associated trauma; assess central and pe-
ripheral neurological function.
(4) Administer Ringer’s lactate; titrate fluids to maintain
adequate urine output or to flush pigments through
the urinary tract (see urine output above). Useful lab-
oratory test: arterial blood gas levels with acid/base
balance.
(5) Using pillows, elevate burned extremities above the
level of the heart. Monitor distal pulses.
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